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Doing the unthinkable

 
Friday, 16 June 2017

Doing the unthinkable

Disappointed by the result of the election? Console yourself with the thought that none of the alternatives would have made much difference to the NHS. Regardless of election pledges, all parties face the same economic reality, which permits very little room for manoeuvre.

Even allowing for Mrs May’s remarkable post-election discovery that austerity was just a bad dream, financial pressure on the NHS will continue. It will endure for as long as we are unable to provide as much healthcare as people would like.

That pressure has been greater in the past decade or so than in the previous decade, and may be greater in the next few years than anything we’ve seen yet, but we’re fooling ourselves if we think it ever goes away. Even if we had a satisfactory definition of need, it is unimaginable that the NHS budget could keep up with it.

The central question is not “How much is enough?” but “How much are we willing to spend?”

In the recent history of the NHS, dominated by a government whose dislike of raising taxes makes it ambivalent about the public sector, the question we have continued to address is a different one, centred on efficiency: “How well do we use the resources we have?” And the answer, despite trusts’ magnificent efforts over the past 12 months, continues to be: “Not well enough.”

The Lansley reforms were an expression of the belief that optimal use of resources is a structural issue. It’s safe to say that this theory, like the numerous experiments in structural reform that went before it, can now be retired – and equally safe to assume that it won’t be.

Meanwhile the efficiency question continues to dominate discourse and policy.

Earlier this month, the HSJ published a story about the latest plan to exert financial control on the NHS. Assuming the story is true (and the HSJ has a good record of getting it right) there is to be a new “capped expenditure process” applied to 14 areas, forcing them to make the “difficult decisions” that will enable them to live within their means – even, according to NHS Improvement, if that means “thinking the unthinkable”.

The impact of the measures, says the HSJ, could be “closing wards and services, blocking choice of private providers, systematically extending waiting times, and stopping some treatments”.

The Office of Budget Responsibility recently published a forecast that the NHS budget will need to increase by £88bn a year by 2067. Dramatic as it sounds in a headline, this is a conservative estimate based on an annual increase in real terms of 2%, only half the 3.8% average annual increase since 1978/79. What’s more, the OBR forecast is predicated on an assumption that we will spend a bigger proportion of GDP on health than we do today.

In that scenario we should be able to keep things ticking over and prevent a serious decline. It may be enough to keep the NHS we have. For the NHS we want, start adding zeroes.

The government’s commitment to funding falls far short of the OBR forecast, of course. We’ve had our frontloaded settlement. Unless the picture changes dramatically, the next two years will be very tight indeed and after that, who knows?  

Long term we continue to hope for solutions involving self-care, healthier lifestyles, better technology, different models of care provision and medical breakthroughs. Some of these may generate the improvements in efficiency that governments and taxpayers long for, but it won’t happen the other way round. Privation does not often produce innovation.

To borrow the hated phrase that has come to dominate NHS commentary in recent years, efficiency is doing more for less – or at least doing more for the same money. But the narrative is shifting: we have begun to accept that what we really mean is doing less for less. 

Fine, as long as we’re clear about that. But let’s not pretend that the net effect on the nation’s wellbeing will be “cost-neutral” or engage in Jeremy Hunt style sophistry about the causal relationship between cost-reduction and quality.

While the regulators bear down on the health economies considered most profligate, demanding that they stick to their budgets, they continue to insist that no decisions should be taken that compromise patient safety. It doesn’t take a degree in philosophy or economics to see the problem with this position.

At best, the measures planned by NHS England and NHS Improvement are just the latest outburst from angry but ineffectual parents who want their kids to know they really mean it this time. At worst, they mark a continuation of a policy obsession with the balance sheet and its terrifying next phase: the transition from thinking the unthinkable to doing it. 

Editor: Julian Patterson

@jtweeterson
julian.patterson@networks.nhs.uk

 
margaret ainger
margaret ainger says:
Jun 19, 2017 09:17 AM

Thing is. No one is prepared to support worse treatment for patients. So commissioners are "damned if they do and damned if they don't".